Provider Demographics
NPI:1063407997
Name:MUTHIAH, ANNAMALAI JR (MD)
Entity type:Individual
Prefix:
First Name:ANNAMALAI
Middle Name:
Last Name:MUTHIAH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 KINGSLEY LN STE 305
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4617
Mailing Address - Country:US
Mailing Address - Phone:757-889-5422
Mailing Address - Fax:
Practice Address - Street 1:110 KINGSLEY LN
Practice Address - Street 2:305
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4614
Practice Address - Country:US
Practice Address - Phone:757-889-5422
Practice Address - Fax:757-889-5450
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222615174400000X, 2085R0202X
MDD00627472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407194800Medicaid
VA1063407997Medicaid
MDP00711682Medicare PIN
MDH10297Medicare UPIN
MD407194800Medicaid
VAP00726451Medicare PIN
MD137689ZBQ0Medicare PIN
DC143827ZCMEMedicare PIN